August 20, 2006
Cesarean spike drives up Medicaid costs
WASHINGTON, Aug. 15 (UPI) — About one-quarter of all children born in the United States — over 1 million — are delivered by Cesarean section, a new report says.
That marks a 38 percent increase from 1997, when about a fifth of all American babies were delivered by Cesarean, the study by Health and Human Services’ Agency for Healthcare Research and Quality found.
Cesarean section, or C-Section as it is commonly called, is an abdominal procedure that involves making an incision in the mother’s abdomen and uterus to deliver her child.
The rise was accompanied by a 60 percent decline in the rate of women giving birth vaginally after having a previous child born via C-section, and conversely, by a 33 percent rise in the rate of repeat C-sections.
The national bill for childbirth as a whole in 2003 totaled $34 billion with hospital stays involving C-section delivery accounting for nearly half this amount — $15 billion.
Medicaid, the federal-state healthcare program for the poor, was billed for 43 percent of childbirths overall and 41 percent of those involving C-section delivery.
Data for the study were drawn from the agency’s Healthcare Cost and Utilization Project, the nation’s largest source of statistics on hospital inpatient care for all patients.
August 1, 2006
Licensure of Certified Professional Midwives
In childbirth, the new makes way for the old
By Eric Jansson
Few women in labor, awaiting the birth of a baby, spare a moment to think of their state legislature. But they might be surprised to learn that, increasingly, state legislatures across the United States are thinking of them.
Following the passage in April of a reform bill legalizing the supervision of home births by certified professional midwives (CPMs) in Wisconsin, similar reform efforts are now underway in no fewer than nine states.
Alabama, North Carolina, Idaho, South Dakota, Illinois, Kentucky, Georgia, Missouri, and Indiana all await legislative debates that could lead to the licensure of certified professional midwives, says Ida Darragh, chairman of the board of the North American Registry of Midwives (NARM), the national organization that tests and registers CPMs.
Legalization and licensure of CPM practices in all these states would represent a massive legislative victory for advocates of traditional home birth.
It would also be a startling rebuke to the many physicians who have long maintained that such practices are unsafe, despite growing statistical evidence that suggests CPM-supervised home births are as safe – sometimes safer – than hospital births.
Well-organized opposition within medical lobbying groups makes such a one-sided result unlikely within the next two years, Ms. Darragh says. But, when asked if the flurry of activity in the nation’s statehouses is indicative of a national trend in support traditional childbirth methods, she adds: “We certainly hope so.”
As with many health issues, the debate about CPMs may seem arcane to non-experts. The debate is a minefield of acronyms, and home births account for just 1 to 3 percent of all births in an average year, with similar percentages in each state.
Yet the debate casts in sharp relief a philosophical tug-of-war over the nature of childbirth that powerfully affects how expectant mothers approach the ordeal of birth.
Elsewhere as in Wisconsin, this tug-of-war pits midwives and physicians who support “natural childbirth” outside the hospital setting and with minimal intervention against the many physicians and nurses who view medical birthing techniques as safer.
When Wisconsin’s reform takes force in May 2007, Wisconsin will become the 23rd state to institutionalize a way for expectant mothers to reject a medical birthing culture entrenched since the 1950s.
Activist midwives say the Wisconsin reform adds bulk to a growing body of circumstantial evidence that America’s popular view of childbirth is in flux, with parents adopting new perspectives on labor and the role of modern medicine in it. CPMs describe labor and birth as “natural” events rather than medical emergencies necessitating medical intervention.
“I think it is a trend,” says Katherine Prown, legislative chair of the Wisconsin Guild of Midwives. “We have seen Minnesota, Utah, Virginia and now Wisconsin all pass laws since 1999. There is a lot of momentum behind these bills.”
Traditional midwifery is struggling to reemerge from the obscurity in which it has languished since passage of Medical Practice Acts (MPAs) by all 50 states, in the 1950s. These acts criminalized the “practice of medicine” by unqualified individuals. They need not have impacted traditional midwifery, but they did in 49 states because only Mississippi offered an exemption for midwives, Ms. Darragh says.
Yet whatever the movement’s momentum, there is also powerful opposition. The American College of Obstetricians and Gynecologists (ACOG), a well-funded proponent of childbirth in the hospital setting, opposed the Wisconsin reform, publishing a position paper stating that CPM-supervised home birth “cannot be considered safe”.
ACOG also urged state officials to take “immediate aggressive action” against “unsafe birth practices”.
Such action was seen earlier this year in Indiana, where state prosecutors earlier this year charged Jennifer Williams, a CPM, with practicing medicine without a license. Ms. Williams, who says she helped 1,500 women give birth safely before she faced any charges, pled guilty. She has since filed a lawsuit against the state attorney general, asking an Indiana circuit court to distinguish between midwifery and “the practice of medicine.” Ms. Williams is also part of the group campaigning for legalization and licensure of CPM practices in Indiana.
The divergence in approach between Wisconsin’s legalizers and Indiana’s prosecutors shows the wide variety of options available to legislators and regulators. States have essentially three options: to legalize, license and regulate the work of CPMs as Wisconsin and 22 other states now do, to prosecute CPMs as Indiana and some others have done, or to turn a blind eye as Mississippi does.
Democratic pressure on statehouses throughout the country could one day yield a consensus, either in CPMs favor or against them. In the meanwhile, those embroiled in the debate are confronted with a growing body of scientific research.
One study frequently cited by CPMs was published last year in the British Medical Journal, an academic publication, by Kenneth Johnson, senior epidemiologist for the surveillance and risk assessment division of Canada’s Center for Chronic Disease Prevention, and Betty Anne-Daviss, a project manager at the Ottawa-based International Federation of Gynecology and Obstetrics.
The study reviewed records of all CPM-supervised home births in North America in the year 2000 and led Dr. Johnson to conclude that “planned home birth for low-risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intra-partum and neonatal mortality to that of low-risk hospital births in the United States.”
Asked to provide any statistical evidence contradicting such studies, for the sake of this story, ACOG sent none but e-mailed two policy statements further explaining the organization’s position on the certification of midwives.
http://www.askdrmanny.com/index.php/pages/comments/in_childbirth_the_new_makes_way_for_the_old/
Links:
American College of Obstetricians and Gynecologists
http://www.acog.orgNorth American Registry of Midwives
http://www.narm.orgWisconsin Guild of Midwives
http://www.wisconsinguildofmidwives.orgStudy published in British Medical Journal
http://bmj.bmjjournals.com/cgi/content/full/330/7505/1416?ehom
ABSTRACT:
Objective To evaluate the safety of home births in North America involving direct entry midwives, in jurisdictions where the practice is not well integrated into the healthcare system.Design Prospective cohort study.
Setting All home births involving certified professional midwives across the United States (98% of cohort) and Canada, 2000.
Participants All 5418 women expecting to deliver in 2000 supported by midwives with a common certification and who planned to deliver at home when labour began.
Main outcome measures Intrapartum and neonatal mortality, perinatal transfer to hospital care, medical intervention during labour, breast feeding, and maternal satisfaction.
Results 655 (12.1%) women who intended to deliver at home when labour began were transferred to hospital. Medical intervention rates included epidural (4.7%), episiotomy (2.1%), forceps (1.0%), vacuum extraction (0.6%), and caesarean section (3.7%); these rates were substantially lower than for low risk US women having hospital births. The intrapartum and neonatal mortality among women considered at low risk at start of labour, excluding deaths concerning life threatening congenital anomalies, was 1.7 deaths per 1000 planned home births, similar to risks in other studies of low risk home and hospital births in North America. No mothers died. No discrepancies were found for perinatal outcomes independently validated.
Conclusions Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.
Full British Medical Journal Article at:
http://bmj.bmjjournals.com/cgi/content/full/330/7505/1416?ehom
July 22, 2006
Maternal Complications Associated With Multiple Cesarean Deliveries
The following article is from Green Journal, the Official Publication of the American College of Obstetrics and Gynecology:
Maternal Complications Associated With Multiple Cesarean Deliveries
Victoria Nisenblat, MD1, Shlomi Barak, MD1, Ofra Barnett Griness, PhD2, Simon Degani, MD1, Gonen Ohel, MD1 and Ron Gonen, MD1 From the 1Department of Obstetrics and Gynecology, Bnai-Zion Medical Center, and the 2Department of Community Medicine and Epidemiology, Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
OBJECTIVE: The claim that a planned repeat cesarean delivery is safer than a trial of labor after cesarean may not be applicable to women who desire larger families. The aim of this study was to assess maternal complications after multiple cesarean deliveries.
METHODS: The records of women who underwent two or more planned cesarean deliveries between 2000 and 2005 were reviewed. We compared maternal complications occurring in 277 women after three or more cesarean deliveries (multiple-cesarean group) with those occurring in 491 women after second cesarean delivery (second-cesarean group).
RESULTS: Excessive blood loss (7.9% versus 3.3%; P < .005), difficult delivery of the neonate (5.1% versus 0.2%; P < .001), and dense adhesions (46.1% versus 25.6%; P < .001) were significantly more common in the multiple-cesarean group. Placenta accreta (1.4%) and hysterectomy (1.1%) were more common, but not significantly so, in the multiple-cesarean group. The proportion of women having any major complication was higher in the multiple-cesarean group, 8.7% versus 4.3% (P = .013), and increased with the delivery index number: 4.3%, 7.5%, and 12.5% for second, third, and fourth or more cesarean delivery, respectively (P for trend = .004).
CONCLUSION: Multiple cesarean deliveries are associated with more difficult surgery and increased blood loss compared with a second planned cesarean delivery. The risk of major complications increases with cesarean delivery number.
July 14, 2006
Article about Planned Home Births
This article appeared on the MSN Lifestyle website:
Planned home birth
Should I consider a home birth?
If you’re a healthy expectant mother having a normal pregnancy and you have no medical or obstetrical risk factors, giving birth at home may be an option for you. Giving birth at home allows you to labor and deliver in familiar and comfortable surroundings. You’ll have more control over your birth experience than you would in a hospital and you won’t have to endure routine medical interventions.At home, as many family members or friends as you want can attend the birth, and you get to share the experience with them in the privacy of your own home, without interruptions from hospital staff. And all of your caregiver’s attention will be focused on you and your baby.
For a sense of what a home birth can be like, read Julie Tilsner’s funny and heartwarming journal entry describing how she delivered her son Jackson at home with the help of two wonderful midwives.
Giving birth at home isn’t for everyone, though. Moms-to-be who are more likely to have complications during childbirth should give birth in a hospital. This includes women with:
– Medical conditions, such as high blood pressure or diabetes
– A previous c-section or other uterine surgery
– Pregnancy complications, such as premature labor, preeclampsia, twins (or more), or a baby in the breech position at 37 weeksIf you choose to have a home birth, it’s important to remain flexible and understand that complications that will require you to transfer your care to another provider or give birth in a hospital can arise during pregnancy or birth. You’ll also need to be committed to giving birth without medication, preparing your home for the birth (getting whatever supplies your caregiver recommends), and making plans to ensure that you have good support available to you in the days after you give birth. Another consideration: Not all insurance companies and HMOs cover the cost of home births.
Is giving birth at home safe?
For healthy women at low risk for complications who choose skilled and experienced caregivers and have a good system in place for transfer to a hospital when necessary, most studies show that giving birth at home is just as safe as giving birth in a hospital. They also show that moms who planned to give birth at home (regardless of where they ended up having their babies) ended up with fewer interventions, such as episiotomies and c-sections, compared with a group of equally low-risk women who had planned hospital deliveries.
But home birth remains a controversial issue in the United States. The American College of Obstetricians and Gynecologists (ACOG) still contends that the hospital is the safest place to give birth because you have the capabilities of the hospital setting and the expertise of the staff there immediately available if a complication arises suddenly.
On the other hand, both the American College of Nurse-Midwives and the Governing Council of the American Public Health Association support the choice of women who are good candidates to give birth at home, and believe that qualified caregivers, along with appropriate arrangements for backup and transfer, should be available for moms-to-be who desire this option.
If you’re not sure whether you have medical or obstetrical problems that would preclude you from having a home birth, contact a home birth provider and share your concerns over the phone. If there are no obvious reasons to rule out a home birth, you can make an appointment for a first prenatal visit. At that visit, the caregiver will do a detailed history and physical exam, as well as the usual set of lab tests. She’ll continue to assess your situation throughout your pregnancy and during labor, birth, and the postpartum period.
What else can I do to make sure that my home birth is as safe as it can be?
Find a good practitioner
Look for a certified nurse-midwife (CNM), a certified direct-entry midwife (CPM or CM), or a physician with plenty of experience delivering babies at home. Ask her about her education, her credentials, and whether she’s licensed to practice in your state. Be sure your caregiver carries necessary equipment and supplies (such as infant resuscitation equipment and oxygen, IVs, and medication to stem postpartum bleeding) to start emergency treatment if needed. It’s also critical to make sure that she has an arrangement with a qualified backup physician and a nearby hospital in case you need to be transferred.Make sure your back-up plan is solid
Make sure the backup hospital is relatively close and that your transportation there is fail-safe in case something goes wrong and you need to get to a hospital quickly.Find a supportive doctor for your baby
Establish a relationship in advance with a pediatrician or family doctor (or group of doctors) in your community who’ll be able to see your baby a day or two after he’s born and is, ideally, supportive of your choice to deliver at home. (Your caregiver should be able to recommend one.)Line up postpartum help
Arrange for extra help at home in the days following delivery. It’s great if your partner can manage to take time off work to help you and to share this special time. If your partner can’t (or if you want extra help), then have a relative or friend come to stay for a few days, or hire a postpartum doula.How much does a home birth cost?
How much home birth practitioners charge varies considerably from place to place and among caregivers. It’s a good idea to find out not only what the home birth will cost but also what additional costs you’d have to pay if you needed to be transferred to another provider or a hospital during pregnancy, labor, birth, or postpartum.
Some insurance carriers cover home birth, but others don’t. If you have insurance through an HMO that doesn’t have an in-network provider who does home births, you may be able to get the HMO to provide some coverage for an out-of-network provider, although you’ll probably have to be persistent.
How can I find a caregiver to attend my home birth?
– The American College of Nurse Midwives in Washington, D.C., can direct you to home-birth resources, including a list of certified nurse-midwives, in your area. You can call the organization at (240) 485-1800 or visit its Web site.
– The Midwives Alliance of North America is an organization for both direct-entry midwives and certified nurse-midwives. For a list of members in your state, e-mail the alliance at membership@aol.com. You’ll find some information about home births on the group’s Web site.
– Ask a childbirth educator in your area or contact your local La Leche League.Fact-checked by the BabyCenter Editorial Team and approved by our Medical Advisory Board.
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